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Thyroid stimulating antibodies (TSab) interact with the TSH-R and stimulate adenyl cyclase and the protein kinase A pathway, as well as the phospholipase C pathway, thereby triggering thyroid hormone synthesis and cell proliferation (227-229)

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However, other studies have indicated that HLA-DR antigens, such as DR2 and DR4, may interact with closely linked genes to influence susceptibility to conditions such as pernicious anemia, which can be associated with cobalamin deficiency [154, 155]

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Energetic intake should be provided by infusion of dextrose 1030% and a 20% fat emulsion (Intralipid) to provide supranormal caloric intake to avoid catabolism with a transition as soon as possible to an oral diet with anti-emetics if necessary